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HomeMy WebLinkAbout1491A (8) �, �.. �.. y�- _ � — �_ __ _.. __ :,_.� ,.., _� � . _�_, .�r..f, . _ . �>,_ .. , �»-�, .._ � �� _�._m_,.. �_ -_ _, _.. � � �WORKERS COfJ�PEN5A710f�+DECL,d�qATY�N' �`� � ' � . . ,�_,. , .,. �_ . . ... :: � gcerr�fedco�mthereo'f Sec�'80�1;Ra6Ceao,f consent jq se�f � . : ,� ���� �F msu e b o 2e t f cote of Wo kers'.Compettsat on Insurance,-ot'" ' '�� �dAb<ao /� ,. .- . . . .. ceeas(iteue.r9i -.:�... , - , ...�. ��r/1� ��°`� /������� -r�c"r� ww. mK� s�.,w �'..,��au.�,� � � P i�cy No-�i��omppny� .�`n't'i�� �'i'llYiC� .. OOs � . ��Olr����yrV n � .. . _.�.. .... �< � t� , SEWER - BEW��E �37���!l�_:`s�..,, : ,r d Certfe c herebyfumishec� , , ,�.�__, . � ; �� . :� �.. � . � . _,.,,.�<.. ��_..U�._..� „. ; ��.. �erhfreQ copy is�:filed wuh thz caunty bwlding inspeciio� � '� COUNTY OF LO$ANIiEi�S BIn�DI��a i�1�b��X►�'`�� Y,M . �'�'7 i,,�.,,.�epoe irtent � � - . .. . .• - . .. � o ie 8 20 8��A�pspl�<e�a+nr �''Y'@E'�`� � FOR APPLICANT TO;�FTLL YN ". • CONNECTI�N D/Cl'%C`�""`"�'��`' s,:��� �{�T�����t UK t1�� q� . � . BUILDING � •F � "�� . �"���.'��{PEN�TIO�VI�URA�CE �v,�• �. .3 X' ADORESS� �� - STATION� DEPTH 't ; 4�,�,„, '� ;; , . . .. .. . - . . � � � f (Th�s settion need npt be completed if the work mvolved by the ia�A��Ty � . a.e.NHoieReFeaer�ce ' '� " " ' UPPEIX ��� p�rmit is`for one hundred dollars.($100j or less) ��� � � -�- " "-- LO�R g,., .�.a ..-,- ,.. .,.«n�n_., c.,. _��. •�.p-, ••. � .. NEAREST �:_ � TYPE'OFCbNNECTION: _ �� ' tENGTr4FRO/h' � I cerbfy ihPt i thQ-pe�orrriance of ihe-work�or wN'it�+ this 4ko555r. �� �v cf1R0. Pt -�- Fnt'70aT-' `�pe m t s'ssoed i�sFall ot employ y p�rson n any manner � - � � � �� v:c�.no �� �s f b e 6� t� �h Wo ke Cortp sai 9 la OWNEg- ,(�]��` �,7r� .p .,. :.a �o i,mv No.� � . . Joe No " �- .- s'"c'�2' � r:c, �h` k°';r,'t�x c �-a e*WP E�'>,v �..�'�'� ;✓ ,�; . . ... _._. .... .. - ... � '�, �s 4.� �r+.���e, �--..- � .'+ '� M41[ � n +� [] �� TRUNKPERMIfIJO., . ... RO'/i4G�CRia11"K�J`.�..<......,,...-�.+�..,,.-...,- ,c AODRfSS ��7�.��X'J��7 '- VOt¢ A(]�JI COflt .� �h . ��� .- . � ...�� AFFIOAVIT� WAIVEk EhSE��NT RECORD INSTp"I�fO. DATE. . 4� n .'Lx4 <«g..,s�,u� , ,v.e.,....,. .,s �7 ��YICCE TO�A�P�LICANT"�f, a'�ter makmg th�s Ce�rtificore of �iTy ��. Cpj7�,j'�, ,TE}.rvo $�.$� E.3 f'�'���Q,�, �.�„�,gmption you.should become subjecf;.lo the Workers' -- ��--^� _- - --��-- � - _-_... . 4F.Z"+Af`. .•,.�� '�.P �sp'�tis'8hon pravisions of the L66or,code,you musr forthwith -� .' oesEkierioN" [oiNo -Hwv.os sr:�wioEUIN�-"��-� '� �� "� ' � �- �� � ��- � � ��. nply Wirh su<h prov sions or th pe m Y.hoal b deemed, � � , 2�.C�''7G4 � � � - _. v Y�okOCI ��y . - . � BLOCK:. �.FRACT �._ , � .l ' STA7E ENCROACHN{FNT �.'� . .... ... ' } Y�rt LICEN���b�� k:� .as�.« `•.` -+� . . NQ OF BlOGS " ' . CERNu"IJO ' . � �.,� �.p„,��;�, .ss.,..o.����'� ,. .... SIZEOKtiOT -� .- NOWON:IOT � �,.;�(�iereliy aff rm fhat I m f tensed u.„nder prnxas ons af Chapter use oF`-� �- ' �� � � �- z�� 9 jcommendng with Secton 706d)of D�v�so 3 of the:B s g��pINGS .,Ci��t � RE35a � . „ � - cHnaces "� -�- � ��:. ness�ah�d'Pro'�essions,Code,6nd my I cense is in full foree and - y��-��q-� �-{ �.7 �y� ,� :.._ , - � � .. ... - ��, e��EC} . . CONTR/'C70R y+��,Cj�;,uy� yQyy�y� CONNECTfON:CNARGEFEE � � � �� LicenseNum6er� ����_�,_Lc ClnssC�_ �- zooRess � �� '����µ` � � Re+MeurzSEt�NT� � 0 �' �'�' � � �' /� /� � � ��� �DISTRICT NO. GkOUP MAP � pROCE55ED fiV��� � V : Contractoe�l"L2ffi$11 Date 81`��,�BV . aTv ���."�r1 �QT(!$ iEi No, �. $Q'�.� `Z . ; a'd` ..., -7 ::,8... . ._ ,'. :.� . . : .: . . . BK PG Z . , �� ,�.. .._. .. �r` ❑I om�e.xerrrpt under Sec � �� of the L A Co , �. uT ENSE NCS 48�7 , �oass ��4 �. � � — .. F � , . ; : . .. , N .. -� Pfumbi gCodeand/o Sec 9fthe �� -� DESCRIRT10h1OPWOR7C` �f'� ' FiNA� � � .. . � " � � � i+ouses�wewcor�r�crrNGro`� onre ��r���-� VALIDATION o, ' `x � '�'P`C�fo t�ie iof�ow ng reasorr ��P�aucseweR . �, Q(� � � . � � � y ��� .� ry�: - �, .. -SEPiICTANK$EEPAGEPITpR �'� , ,_, . . - Z � P1T5 ANb/Ok"tlRAINf�ECb` � FlNAL . ,: .: . . DPfO : :. BV . . : y , - ---�+-�—�--�--- -HOUSE SEWER,CQh7F7ECTfNG TO � % ` :. �Y.�, .. . �. PRIVATE DIS AI.`5YS7E ��� . . . . . . . .0 S cfnOtUf@ '- �� �� � CONNECT ADIflYIbN'til Bl.OG"bl£ '�� ""`�'`"' . ,. . . . ... . ,,, ty-,OW1+f�R$�CTIY�� LVORKTO HOUSF'SE�VPR'. �. ' . _ . " , . -' ���A�'�k�*��' � '�P`/ERF�OW SEE�AGE,%T�RAINFjELD - � � � � I hCf2fJy offN'm ihtlt l�am ex@mp��fY0711 ih9 COnffaCfOf 5 LiC2nse E%TN,CE5SPOOL,DRVWELl,MANHO[E � �aW{o!thE{O��OWi�9�_retl5011�($CCt0l1�Qa1.5,BViSIICSS anC�Pf0 - ALTER,kEPAIR'OR AB{JJDONH005E ` � . . .�ry.yF(�1 1 �1. , , � O sC0(IC� .:.. � SEWEROR�15Fd§A�S"YStEM""�..��' .,. . . . i .. � r� �����I s o er of the�property,or�my employees wrth wpges as � � � ;':�a�ta�m��1 L� �: � ��i the r.sole compensot on w II do the work and Ihe sYructure , ,,_ �- � -_� � �` s not intended or offered far sale(Section 704'4,B'usiness � �. � ' ""� ��� �"'���"� � j �'2_'�,�U .� � �, , _, .,,,-rh ��m � ' - ❑nd'Pio4e5sionsL`ode) '� � � �W►�FR'$�� POelTlit �. $ � �� Q . � �I as ownzr of the properry,am exclus�vely co�tracrir�g with AUTHOit(�A7I�N TOTAL FEE `� Q �:K q��,'�[1 r=; �' �`'�' Gcensed contractors to cons�ruct rhe projecr(5ection.7044, ' r HnVe n"Hts onie'Q coNYkAST":y.%C}P'THE`HERE'iN Wii�,SAD CO"NiRAcrOR Yo�,, � � Bus nes's anc�Professions Code) � coNNEcr*HE neovE'rlfscaieEo"�X�snFYG'bVSEtIlW'G4�'T�iE"v�Lt4'IE0✓Eh . � . � -jJ.B,�^y�F'p . ? °CdY�57�RUCTIO��L�h11$%1TG AGE�M1,�,I�'(r "'�'�"""'�� . �.. � �-�� . '� I hereby��affirm that Ihere is a-wnSTruction lending dgency StGNED�TH15 �� QAYO ��� 19��� `- fo rhe performpn[e�of ihe work for wh,ych ihis permrt rs aWroER�oa :' . , . � `-� issued(Sec 309T C�C) . owNeas ��nr_/�. .n^+v1 Y �C�A/'��_ . . .: { �, ..�, Z , . .: .. �.: '-'<A ADDRE55,Q�J^� +� . -" Lender s.Nome � � . _ . �iq� � .: "l. ..,.:_... . .z� ._. ,�.x ;Z?' ,�': a�..'�'E7AY'. adr'(w:� � ,4- 3�,x t . _ .. . - . �.�..-�....�.M....w.,a.,.....a.... 4ender s Add e s . - . .,.- . � ""'""�— "`"""'"`"' .. . - . . � ..w..... w�..,�...� .._,.�.»,........+»�.�,.�.,.x,.,..,M...�.R......a...n...,..�,... ?;; I ce.YiyRthat 1'hoye�.read �hs dpplicahan and sime that the . . . . � � _ . � , _ '.u� pbo e.i,nformation is gorrecf,I.agree ip.comply with pIl�CouNy��.. . � � . �� - . . � � . . - 'C ord nart.ces and Stote lows regulafng�Plumbmg and�Sewers, . �. - -� . ? a� hereby authorize representat ves of,ihis County.to enrer ' � . . ;, f�- . -.: ��; �� . �:� - � ,,. �. :..: . .. .: �..,, .:_.. ..: . - . . ,�•��. vpon"ff�e abave ment oned property for mspeciion p�rposes. ` '' . ..�'..� . ,� . '� � , . ' �, ° s �� `��..�t,�vH�n.- �� �L��`� �� � _ � . _ .. •; 5 gn¢t e f Permitte Pate , ..,� , . _ R E9SStJI .,.., - �• , � SEE RFV�RS�Fb 1VA701fV�TANGOAt3E" � y/EA'Y .n;`..4`� �TY" Hz �^`u"'> .9 E v�ry _ ..�',t. �/: ' ci` :r ' '""•,t �t 4 J .�'Jr; K Fa- }r�3: � r �a�^ =z s;�,��� IMSPEt70R'SNb4� �3���..�A��$�ECL�a�A'd��N � " � � � _ ���s �;�a�,� ;.��,.�„`�...z .� .. :� „ ��,��,� �. . ��..M a..., ,,... :, ,,,: ,,. +#^� , � .��- a ,f_ :-� r�.,.+rp,r�� wv .; a E.;.,..:. APP�OV ALS � on�� s°r+s'v[cfoxs'stcwn�uit��. � .. ..: . , I herehy affiam e�aa 3 am�xempe�ea�e Cc+utracRar's.. New wousE sEwea � W..... ... �..,x.. .�,,w,�� ��ss a�ed�r aions�Code�Aoyr ta ats€ss 3i.5, r tfie fo3lowin�re�saa(Sectrma 0 BUILDIN60RWORK ss ,�.. �r� ��x��. �,= CONNECT ADDITIONAL' � . . .. . . . ��YBd td jJE9'fldLl rG COlAi$71/CL{. 11YOU6� ` .,.,..�� ....,� .� ,. .�r,.� ,�._�r..,„, �... � +� ,'Y 'P� , acattCe: � '. SEPfICTANK�SEEP,PI((5), "� •• ', � . A�40 f2Qf&4fC.0 d�.�,$�174i81tG f6P Sf6C�s�B9Y9Ybt f.0,�616(d ��. .}'r'. ANDIOR�DRAINFIFLO - - � - . � � „�n-.'.. . ;... . . •." . �� .. .• - . SigBl�S$6E¢!l3Ekd S�6$dJF tl3��tCE8R6E�11ldTSNf41B$$o E{9.E ' `K.�.CESSPO.OL.O.. DRYWftIL�J � � :�... , ,� ...,... :,., :.s,,..�.:.... w:�.... ... . ..::..... . . . � � .. .. ... •:- ,, , � . pronisioas,of tbz�Cox,tractor'r Lis$snce Eaw(Cb ter 9 ,:.- -,•, �,� /rommesuvng wdt�Seetion 7000)oJ Dtvissoes �tbe � � Al7ER,REPAIR.SEWEROR x.,.�....e„-..«�..a.z"��we��z-��"�.�...., ...x.us,..,zta.., �, �TM"� sEwnce oisrosni svsren� .-. .... . . . .. ...., , '^^ Brissaess'ond Prafessdosxc CadeJ or 3baa be 4s exempt ' �^�I: quoraNecr au�nno , _. . . . � �.... .. .� ., ' .... ..._. �.... , tbeCe.from arrd tFia:Saslsfor a6e adleged s�sss$lion.�Any �:=.�.nanNooH Ftouse sew�t �.�� .. . .�: .F,-...�.a. .N--�.:•.»._..�,....��,.. _<..,o..=,.,.,,za.�'�ioYatimt of SeeEf�a 7031.51+3'a�y egQl�deraxSfoztaPernae2 Y .BACKFlIt SEPrIC'TM'KS Q . � ,. . sYdbj¢tts Ebe GQfI�iCA93f t0�2 eY9JE1 pGfX[i�ty of 9JOl fllOi'B P�SE �,-- �a wr sl f� cessroa.s Cl rt � .� � �� 1`we bundred do8dars�$900%: g, .. ,. ' - _ .; „� : -�❑T,as cte aswnea of thepmp�wwili�do the evotky and .�-_'� . _._: � : ,' _�� _. � �- . , ., , �; .•r;er .<-.,� . .:� � ,a � .�.,s *y ��.: �t ��t t' . ' �the seencture is�aot imtended ar oifered for sa1e., . y�,.i.: -, t � y.� ';�� � .;.` - .; '� (Sec 7044,Bttsiaess and Pa°of¢sssows'Ctide°'T"1�"'�?oa- _ � a._ � . .; . s . :,. ,.fr y �*�a- `�"_ �actos's Lfcenss Law daes seot p8y�to av�o':, ..of � ,....„,,� �; �.r "r :� er"ty w braidds or dm�aes t�'uereoea;amdwbo�do�s ,:.... _ �C�' � �� .: �� ucb movkffibsmtelf ps»vidcd tbas sucb im `�,__ , t s pawvem � r__ � _ ..,. �.'': . ' ena � are itut s'ntended or ofJered for saJe If,kowever, 3Ae � � � .., �.�� _�. :- , �. ;- � � ._< ,'°t.�: �"-•r'"�� `bwi •' or imprpoem�mR;f�.sold uxtbi�s ao{e�ekr�rxf .,_;. *s ' ld�mg J' .�� � ,, .; - �- . ;� _ .. r r�q�, c Cr <. conipletion. tbs�ownerbre37d'er aaitF baye t�e,@ipsrdeae� �' ' " - �:� a,�,�.� �;-� ��e��';rt�� ^" �- of provsog tbat�be�xot bwJrt or zvrcpsove for 2be � dxcrpose of sale) s , ` ' j� �'3 ^t3i�,a`:�"3��+ �x� r�� ��:� � k�..��� :: c �� � ' .: - _ _ ... � ,,,, �� , � �'""�-�---�+ xs .. .. „, . _.�.C �r. �., , � �- , .,.- 8�.�£��' ., .. ., , �� s'�i . :. ; , � . . , : � �t U�dCR' � a-„ ,� � �,� r, '� �!��r) ���.��ti� �B&P� $or tlais reason � ,r : �s� �- � � .., - � � _, �..~. �_ , _. ,._._ _ .� � e '�- � � �.,. i h @;" '°F ) ;�..+�`�,'�. 'A:h tY .:.��.� ...t v� �s:�n ag�^., � „,. .. _.. ; - a . . . . - "; .,r _ _ __..�._. ` � � :, ..� , ... . ... _ , ,. 3 . 1� s � y...�. _ . �..� _ � mS S t-. 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